Vital Signs

Guidelines for measuring VS

measuring accurately and in a timely manner = your responsibility as a student nurse
- make sure all equipment is clean and working properly
- know pt's baseline measurements (typical range + PMHx)
- keep pt comfortable and ensure privacy/safety
- documen

Vital Signs

Temperature, Pulse, Blood Pressure, Respiratory Rate, Oxygen Saturation, Pain
indicators of general health status + effectiveness of circulatory, respiratory, neural, and endocrine body systems

Temperature

Measured in �C or �F
Reflects balance b/w heat produced and heat lost by body functions to environment
insight into effectiveness of neurological and cardiovascular systems

Temperature Acceptable Range + Sites

96.8�F - 100.4�F
(36�C - 38�C)
Oral, rectal, axillary, tympanic membrane, temporal artery, pulmonary artery
rectum. tympanic membrane, temporal and pulmonary arteries, esophagus, and urinary bladder = core temp sites (reflects internal temp)
skin, mouth,

Heat production

results from increases in basal metabolic rate, muscle activity, thyroxine output, testosterone and sympathetic stimulation

Heat Loss

occurs through conduction, convection, evaporation, radiation, diaphoresis

Expected Temperature Ranges

Oral = 96.8�F - 100.4�F (36�C - 38�C)
average --> 98.6�F (37�C)
Rectal = 0.9�F (0.5�C) higher than oral/tympanic temps
Axillary = 0.9�F (0.5�C) lower than oral/tympanic temps
Temporal = typically 1�F (0.5�C) higher than oral, 2�F (0.5�C) higher than axill

Temperature Considerations

- Age: newborns have large surface-to-mass ratio and very little fat --> greater heat loss to environment; older adults = loss of subcutaneous fat, changes in thermoregulation due to aging
- Hormonal changes: temp rises slightly with ovulation and menses,

Nursing Interventions: Temp

Equipment: thermometer
Procedure: hand hygiene, privacy, clean gloves
-Oral: place thermometer with cover under tongue (lateral posterior sublingual pocket)
-Rectal: more accurate measurement, assist pt into Sims' position w/ upper legs flexed, ensure pri

Fever (pyrexia)

Measured temperature x > 100.4�F (38�C)
typically not harmful unless it exceeds 102.2�F (39�C)
heat loss mechanisms = unable to keep pace with excessive heat production
Febrile: feverish
Afebrile: without fever

Hyperthermia

Abnormally elevated body temperature greater than 104�F (40�C) due to failure of thermoregulatory mechanisms
-obtain specimens (blood, urine, sputum, wound cultures)
-assess WBC, electrolytes, and sedimentation rates
-keep pt hydrated, provide fluids, enc

Hypothermia

body temp less than 95�F (35�C)
-warm environmental temp, warming blanket, keep head covered
-provide warmed oral/IV fluids
-continuous cardiac monitoring
-have emergency resuscitation equipment on standby

Temperature Regulation

Hypothalamus controls body temp (think thermostat --> negative feedback loop)
heat = byproduct of metabolism

The nurse has delegated VS to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to:
A. take a rectal temperature
B. take the oral temperature as planned
C. ad

D. wait 30 minutes and take an oral temperature
recent food/liquid intake can alter temperature readings
you would not opt for a more invasive procedure like taking rectal temp unless absolutely necessary

Pulse (Heart Rate)

Measurement of heart beats per minute and rhythm (HR)
Provides insight into circulatory system status
count for 30 sec x2 unless abnormal findings are present
electrical impulses originate from sino-atrial (SA) node

What part of the nervous system controls heart rate in the body?

Autonomic nervous system:
Parasympathetic nervous system lowers HR
Sympathetic nervous system raises HR

Expected Heart Rate Range

adult --> 60 - 100 beats per minute (bpm)
rate = number of times per min pulse is felt/heard
rhythm = regularity of impulses, should be in regular intervals
strength (amplitude/pulse volume) = volume of blood ejected against arterial walls with each heart

Pulse Considerations

- Dysrhythmia: irregular heart rhythm, irregular radial pulse typically palpated
- Pulse deficit: difference b/w apical rate and radial rate; to determine accurately, two clinicians should measure apical and radial pulses simultaneously
- Age: expected fi

Pulse points (sites)

temporal
carotid x2 (measure one at a time to avoid discomfort/injury)
brachial x2
radial x2
femoral x2
popliteal x2
posterior tibial x2
pedal x2

Nursing Interventions: Pulse (HR)

Equipment: clock/watch, stethoscope
Procedure: hand hygiene, privacy, clean gloves
Locate radial pulse with index and middle fingers, assess firmly for rate, rhythm, amplitude, quality
If regular, count x30 seconds and multiply by 2, if irregular count x6

Tachycardia

abnormally fast HR
greater than expected range (x > 100 bpm)
-exercise
-fever, heat exposure
-medication (epinephrine, levothyroxine, beta2adrenergic agonists--> albuterol)
-changing position from lying down to sitting/standing
-acute pain, stress, fear,

Bradycardia

abnormally slow HR
less than expected range/slower than 60 bpm
-long term physical fitness (athletes)
-hypothermia
-medications (digoxin, beta-blockers like propranolol, calcium channel blockers like verapamil)
-changing positions from standing/sitting to

Pulse Nursing Diagnoses

Activity Intolerance
Anxiety
Acute Pain
Decreased cardiac output
Deficient/excess fluid volume
Impaired gas exchange
Ineffective peripheral tissue perfusion

You notices that a teenager has an irregular pulse. The best action you should take includes which of the following:
A. reading the history and physical exam
B. assessing the apical pulse rate for 1 full minute
C. auscultating for strength and depth of pu

B. assessing the apical pulse rate for 1 full minute
if an irregular radial (or any other peripheral) pulse is palpated, count again x60 seconds and compare it with the apical pulse using a stethoscope x60 seconds

Respiration (Respiratory Rate)

Measured as breaths per minute (RR)
Insight into lung gas exchange and respiratory system in general
count for 30 sec x2 unless abnormal findings are present

What monitors the CO2 levels of the blood?

chemoreceptors in carotid arteries and aorta --> rising CO2 levels trigger increased RR which rids body of CO2 faster
clients with COPD often have increased RR because the body is constantly trying to compensate for the low oxygen levels with a primarily

Process of Respiration

Ventilation = exchange of O2 and CO2 in lungs through inspiration and expiration, measured with RR, rhythm, and depth
Diffusion = exchange of O2 and CO2 b/w alveoli and RBCs, measured with pulse oximetry
Perfusion = flow of RBCs to and from pulmonary capi

Expected Respiratory Rate Range

12 - 20 breaths per minute (adult)
observe rate, depth, rhythm
do not inform pt when measuring respirations to avoid any intentional/conscious alterations in breathing pattern
rate = number of full inspirations and expirations in 1 minute
observe number o

Respiration Considerations

- Age: RR decreases with age
- Sex: Males/children = diaphragmatic breathers with more abd movement, women = use thoracic muscles w/ more chest movement
- Pain: acute pain in chest wall --> decrease in depth, will stabilize over time
- Anxiety: increased

Nursing Interventions: RR

Equipment: watch/clock with second hand
Procedure: hand hygiene, privacy, clean gloves
Place pt in semi-Fowler's with chest visible, observe for full respiratory cycle (inspiration/expiration) x30 seconds if regular, x1 min if irregular
depth (shallow, nm

Bradypnea

abnormally slow breathing
regular breathing pattern w/ rate x < 12/min

Hypoventilation

shallow breathing pattern w/ slowed rate

Hyperventilation

deep breathing pattern w/ increased rate
leads to decreased levels of CO2 and hyper-oxygenation

Apnea

periods of no breathing
can lead to respiratory arrest

Tachypnea

regular breathing pattern w/ rate x > 20/min

Hyper-pnea

RR, depth, WOB are all increased
common with exercise

Cheyne-Stokes Respiration

irregular rate and depth of respirations following a cyclical pattern
shallow breaths that progress to a nml pattern w/ increased rate then rate begins to slow which ends with an apneic period

Kussmaul Respirations

increased RR, regular pattern, abnormally deep

A postoperative patient is breathing rapidly. you should immediately:
A. call the physician
B. count the respiration
C. assess the oxygen saturation
D. ask the patient if he feels uncomfortable

B. count the respiration

Blood Pressure

Measured in mmHg as systolic BP over diastolic BP
Reflects effectiveness of the heart and cardiovascular system in general
obtain BP with stethoscope and BP cuff after palpating for brachial artery pulse
Systolic BP (SBP) = max peak pressure during ventri

What are the principle determinants of blood pressure?

BP = CO x SVR
Cardiac Output (CO)
determined by
-HR
-Contractility
-Blood Volume
-Venous return
Increases in any of these increases CO and BP
Decreases in any of these decreases CO and BP
Systemic/Peripheral Vascular Resistance (SVR) = amount of constrict

Classifications of BP

Nml:
-Systolic (SBP) = less than 120 mm Hg
-Diastolic (DBP) = less than 80 mm Hg
Elevated:
-Systolic = 120-129 mm Hg
-Diastolic = less than 80 mm Hg
Stage I Hypertension (HTN):
-Systolic = 130-139 mm Hg
-Diastolic = 80-89 mm Hg
Stage II HTN:
-Systolic = g

Hypertension (HTN)

Abnormally high BP
Not classified as HTN until you have three readings from separate occasions all with elevated SBP or DBP
thickening of walls, loss of elasticity, more common than hypotension
Assess/monitor for tachycardia, bradycardia, pain, anxiety
as

Hypotension

Abnormally low BP
can result from fluid depletion, heart failure, or vasodilation

Orthostatic (Postural) Hypotension

sudden drop in BP that occurs when client changes position from sitting/lying down to standing
may cause dizziness/syncope to occur
assess for dizziness, weakness, fatigue, fainting
advise pt to sit or lie down if experienced
keep call bell near
have pt s

BP Considerations

-Age: infants j=have lower BP that gradually increases with age, older adults have slightly elevated SBP given decreased elasticity of blood vessels
-Circadian rhythm: BP lowest in early morning hours, and highest around midday/afternoon
-Stress: fear, em

Pulse Pressure

difference b/w systolic & diastolic pressures

Nursing Interventions: BP

No nicotine/caffein x30 min prior to measurement
Rest x5 min prior
Have client sit up, arm supported at heart level, feet flat on floor uncrossed
Do not take measurement on side with IV or side where client had a mastectomy if applicable
Average two or mo

Oxygen Saturation (Pulse oximetry)

Measured by percent (%) of oxygen saturation of blood (oxygen level of blood at a given point)
Demonstrates effectiveness of lungs/respiratory and circulatory systems

Expected Pulse Oximetry Range

95% - 100%
Clients with chronic lung disease may have baseline levels as low as 85%

Nursing Interventions: Pulse Oximetry

the same factors that affect RR affect oxygen saturation
Equipment: pulse oximeter
Procedure: choose intact, non-edematous site for measurement, place digit probe on client's finger (earlobe/bridge of nose for pts with peripheral vascular issues and dispo

Pain

often noted as the 6th VS
measured as a subjective finding typically on a numeric scale from 0-10 (0 = no pain, 10 = worst pain imaginable)
Wong-Baker pain scale uses images or emoticons to assess pain in pediatrics
Subjective finding
pain = individualist

Safety Guidelines for VS

clean devices between patients to decrease risk of infection
rotating sites during repeated measurements of BP and pulse ox to reduce risk for skin breakdown
analyze VS trends and report abnormal findings
determine appropriate frequency of measuring VS ba

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.8�C (101�F), pulse rate of 114/min, and RR of 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Sel

A, C, E

A nurse is instructing an assistive personal (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring VS for this client?
A. "Do not measure the client's temperature rectally"
B. "Count

A

A nurse is instructing a group of assistive personnel in measuring a client's RR. Which of the following guidelines should the nurse include? (Select all that apply)
A. Place client in semi-Fowler's position
B. Have client rest an arm across abd
C. Observ

A, B, C

A nurse is measuring BP of a client who has a fractured femur. BP reading is 140/94 mm Hg, and client denies any Hx of HTN. Which of the following actions should the nurse take first?
A. Request prescription for antihypertensive medication
B. Ask client i

B

Nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/min